In this discussion post, select an element of the PEAR Model that can assist with understanding the human failures in this real world case study. Explain possible human factors that may have led to the corroded cable being overlooked during the annual inspection. Do you believe human factors explain why there was there an unauthorized, undocumented part installed in this aircraft. Could the PEAR Model have prevented the cable failure, engine power loss, and the resulting death of the pilot? What other questions could the Pear Model help us analyze and prevent something like this from occurring again?
Your post must focus on explaining the maintenance and safety issues, and describe why and what documentation is required. You must use a minimum of 150 words and use proper grammar and spelling.
The PEAR Model: A Case Study
At 1830 hours, September 23, 2002, a Piper PA-28-140, registered as N8828N crashed into an old oak tree in Milton, Florida narrowly missing a home with people inside.
A student pilot, an active duty Marine was killed.
The Annual inspection was completed September 19 2002.
Although the fuel pump was found operational, it was not approved for aviation purposes. The accident report stated: “During the examination of the airframe fuel system, an unapproved part was found. An automotive electric fuel pump was found installed in the system. The electric fuel pump was labeled "automotive electric fuel pump" and "not recommended for use in aircraft applications.“ The log book did not show this fuel pump as having been replaced.
The final report showed that a mixture control cable was corroded due to severe wear. This cable sheared causing the engine to have a lack of power.
According to the FAA Report, "Examination of the engine cockpit controls found them in the cutoff position. The fuel selector valve handle was found at or near the off position. The airframe to engine controls were found in a deteriorated condition. The mixture control was found separated at or near the mounting bracket, adjacent to the carburetor. The inner cable strands appeared worn; the outer cable sleeve appeared corroded. The mixture control cable assembly was removed and sent to the NTSB Material Laboratory in Washington, DC for further examination. The airframe to engine carburetor heat control cable end was found separated from the control arm at the air box. During the examination of the airframe fuel system, an unapproved part was found. An automotive electric fuel pump was found installed in the system. The electric fuel pump was labeled "automotive electric fuel pump" and "not recommended for use in aircraft applications." The electric pump was removed and field tested by applying the aircraft's battery and fuel to the inlet. The pump pumped fuel out of the outlet. The pump was operational. The FAA took possession of the fuel pump. A review of the maintenance logs found no record of the electric fuel pump's replacement."